Internal and Emergency Medicine | 2019
Lumbar puncture after direct oral anticoagulant (DOAC) reversal: a proposed algorithm for the emergency department
Abstract
The case reported by Spagnolello et al. [1] confirms the safety of emergency lumbar puncture after dabigatran reversal with idarucizumab, as suggested by other authors [2, 3], including ourselves [4] (Table 1). Spagnolello et al. [1] re-present the issue of anticoagulant treatment periprocedural management in patients on direct oral anticoagulants (DOACs) requiring lumbar puncture (LP) to rule out infectious diseases of the central nervous system, or subarachnoid hemorrhage. Dodd et al. [5] have recently provided evidence-based recommendations for the periprocedural antithrombotic management of lumbar puncture, on the behalf of the Association of British Neurologists. However, they left how to manage patients on DOACs, a relatively novel pharmacological class, under debate. These authors [5] suggest involving a hematologist to discuss the risk/benefit ratio of DOAC withdrawal and that the patient be monitored for new neurological signs/symptoms, if an urgent LP is warranted outside the time frames recommended for a non-urgent LP. Although Dodd et al. mention the interesting possibility of measuring the drug-specific levels to estimate the anticoagulant effect of a DOAC, they do believe that routine testing of DOAC levels before the LP is unnecessary [5]. As expressed in our e-letter [6] to the authors, we are convinced that this is a crucial point. Indeed, specific coagulation assays, developed for the quantification of DOAC plasma levels, are more reliable than routine coagulation tests for the assessment of DOAC anticoagulant effects [7]. Therefore, when available, DOAC drug-specific levels are useful to guide rational clinical management in an emergency setting. Indeed, as long as the drug levels are below the cut-off value chosen to rule out any anticoagulant effect, LP may be performed immediately. Unfortunately, there is still no international consensus and the various advisory bodies, e.g. Societé Francaise de Neurologie Vasculaire (SFNV) and the Groupe Francais d’etudes sur l’Hemostase et la Thrombose (GFHT) [8] and the Swiss operating procedures [9], set different lower threshold limits for the anticoagulant effect of DOACs. They range from 20 to 50 ng/mL for other urgent procedures, such as intravenous thrombolysis. Therefore, international consensus is welcome on DOAC drug level cut-offs for patients requiring urgent or emergent procedures, such as LP or surgery, to rule out adverse anticoagulant effects. In the meantime, based on expert consensus for the management of acute ischaemic stroke by the 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation [7], which takes into consideration intravenous thrombolysis in patients on factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), if the DOAC plasma levels are below 30 ng/mL, we suggest adopting for urgent/emergent LP at the same reference cut-off value of 30 ng/mL. Although DOAC levels within the therapeutical range are challenging for the clinician, a remarkably different and more straightforward management may be prospected if an LP is indicated in patients on dabigatran. Indeed, although literature evidence remains scanty, in our experience an LP after dabigatran emergency reversal by idarucizumab is a safe procedure, even if a haematologist is not consulted, as a time saving measure, and is in agreement with the recent Guidance Statement by the Anticoagulation Forum, a North American organization of anticoagulation providers [10]. However, clinical and * Eugenia Rota [email protected]